Is epinephrine truly lifesaving, and can we prove this?

Injectable intramuscular epinephrine is the first-line treatment for anaphylaxis. Epinephrine is touted as "life-saving," in particular because observational studies have identified lack of prompt epinephrine treatment as a critical risk factor associated with anaphylaxis fatality. Although association is not causal, few would argue that epinephrine is not the optimal treatment for anaphylaxis, and do we have sufficient proof to suggest that epinephrine is actually "life-saving"? Epinephrine indeed works swiftly to reverse such symptoms of an immediate allergic reaction. However, there are abundant observational data that many cases of anaphylaxis are inherently self-limited and may resolve within 1 to 2 hours in most cases with or without treatment. In this perspective, the intent is to address and reframe the reality of the evidence we do have for what epinephrine does and does not accomplish and provide a perspective regarding the common "dogma" regarding the drug. There is a danger in using terms such as "life-threatening" and "life-saving" for anaphylaxis and epinephrine treatment, especially under the caution of frequently cited rhetoric that subsequent reactions are likely to be progressively more severe or potentially fatal. Use of such descriptions risks negatively polarizing our patients and adversely affecting their quality of life, given these terms can potentiate unnecessary fear. Epinephrine is in fact a wonderful drug, but it is important to not lose sight of the evidence for what it actually does in anaphylaxis treatment and why it is important to use this drug in anaphylaxis, as opposed to an emphasis on what it does not do.